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Tina Brock, David Taylor and Tana
Wuliji, of the
School of Pharmacy, University of London
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The success of NHS community pharmacy and allied smoking reduction services and policies demands recognition. Adults smoking in the UK today amount to about 25 per cent, compared with a figure of 80 per cent among men 50 years ago. With the ban on smoking in public places and workplaces in England coming into effect on 1 July 2007, the UK, arguably, now enjoys the most comprehensive set of tobacco control and smoking reduction policies and provisions to be found world-wide.
But politicians and health care providers must not be complacent: Britain
still has a higher percentage of smokers than countries such as the US,
and an increasing proportion of them are both heavily addicted and socially
or psychologically vulnerable. In the years ahead the NHS is almost certainly
going to have to spend more on smoking cessation support and allied services
to avoid the trap of tobacco use becoming an “under-class” disease,
and perpetuating gross health inequalities well into the 21st century.
The School of Pharmacy report “Ending the global tobacco pandemic” (PDF 1.8MB)
highlights the central role that community pharmacists and pharmacies
can cost-effectively play, both nationally and internationally, in further
helping individuals and populations to stop smoking. Based on two linked
School of Pharmacy surveys of recent service advances (with the international
version facilitated through the International Pharmaceutical Federation),
it shows that pharmacists contribute valuably to tobacco-related harm
reduction not only through their mainstream involvement in giving advice
and supplying nicotine-replacement therapy and other medicines, but also
via specialised service provision.
The latter include the level 2 and 3 services funded as enhanced services
by English primary care trusts, together with schemes such as Glasgow’s “Starting
Fresh” pharmacy stop smoking project and Northern Ireland’s
recently established nation-wide model. The data we have gathered indicate
that pharmacists facilitate at least a fifth of the 500,000 quit attempts
that specialist NHS services promote in England each year, in addition
to the many more self-managed quit attempts they support.
Authorities such as Terry Maguire, who has played a key role in the evolution
of the Northern Ireland model, have suggested that the approach being
pioneered there in the smoking cessation context could open the way to
more extensive developments. It could perhaps lead to the establishment
of independent pharmaceutical care and prescribing budgets like those
traditionally enjoyed by GPs. Such opportunities reflect this week’s
All-Party Pharmacy Group call for an extended range of advanced pharmaceutical
care services to be funded on a national basis. This would be less vulnerable
to local postcode variation in standards of care for the public than
are the current arrangements.
However, the main findings of our research — while pointing generally
to the fact that building further pharmacy services for smoking cessation
offers a template for future role extensions in other forms of chronic
and acute disease management — are focused on more immediately
achievable goals and pharmacy practice improvements. For example, we
find that in many parts of England it would be desirable to simplify
the pharmacy payment structures underpinning specialised smoking cessation
service delivery, and increase the size of schemes to a regional rather
than PCT level. This would decrease the amount of varying paperwork to
be completed, and help improve service efficiency.
Our analysis also points to the need to increase the proportion of community
pharmacies that take a robustly informed and active interest in supporting
smoking reduction, and psychologically facilitating other forms of behavioural
change with regard to health and medicine-taking. As well as needing
appropriate funding structures, this is likely to demand long-term interventions
aimed at building pharmacists’ sense of success in this context
and raising public expectations of the health care that pharmacists should
offer.
Another illustration of an area where pharmacy may need a strengthened
internal debate relates to resolving professional uncertainties about
the safety and overall value of NRT and other stop-smoking medicines.
Not only can these increase quit attempt success rates (by up to four
times when combined with effective psychological support) but they also
allow addicted individuals to reduce their use of hazardous tobacco products.
There may be doubts in the minds of some pharmacists about the probity
of supplying medicines like NRT for any purpose other than supporting
quit attempts. But, as organisations such as ASH have noted, if smoking
proves impossible to eliminate at a whole population level then revised
approaches to tobacco-related (as opposed to nicotine-related) harm reduction
could prove vital for achieving public health improvement goals.
Looking beyond UK concerns, global smoking rates are continuing to rise.
It is striking, for instance, that a third of all today’s smokers
live in China and that, if current trends continue, tobacco use will
cause about a billion premature deaths world-wide in the coming century.
To some observers such stark statistics may seem to have little relevance
to the work of pharmacy in countries such as modern Britain. Yet, if
the profession wishes to play a leading role in a more unified and interdependent
world economy, its leaders cannot afford to ignore such problems. Rather,
there is an opportunity for pharmacy to play a central part in their
solution.
This week delegates at a major conference in Bangkok have been considering
the ongoing implementation of the WHO’s Framework Convention on
Tobacco Control (FCTC). To date, this has primarily served to focus policy
makers’ attention on traditional public measures such as raising
the price of tobacco products, limiting their advertising, and stopping
smoking in contexts where it could harm non-smokers.
But our research
suggests that as such measures become established they must — if
they are to be optimally effective — be complemented by better
support for vulnerable smokers who are seeking to quit, but find it difficult
or impossible to so. This may perhaps be because of social and psychological
stresses or mental health problems. Only one frequently overlooked Article
of the FCTC, Article 14, covers this area. It can be concluded, therefore,
that pharmacy, as a global profession with an important interest in 21st
century health improvement, should work to promote greater investment
in smoking cessation services.
This will involve raising governments’ awareness of Article 14
of the FCTC and promoting its robust implementation. Providing stop-smoking
support is one of the most cost-effective interventions that any health
care provider can make. Pharmacists everywhere would be well advised
to make it a central part of their role, not only to enhance health in
their communities but also to help ensure the future of their own profession. |
The
Pharmaceutical Journal